care plan need to personalize

Ok... just when I thought I had the care plans with nic and noc and the nursing dx going good, I get an instructor who really wants personalization to the specific client. Not "right out of the book". I understand her reasoning but I'm having a heck of a time with it!! Does anyone have any suggestions? What is she looking for? I look at other students plans and seriously - they have copied exactly out of the book and they get a perfect score. I did the same thing with my first one and she tore it apart and wants the personalization. Argg! I just want to learn and become a great nurse. I'm open to suggestions. TIA

Use the ones out of the book, but personalize them to the individual patient/situation...?

Apr 5, '07

If you talk to the patient you can usually find some sort of Ineffective Coping. That's pretty personalized.

Apr 5, '07

Look at the ones in the book, then personalize it to the patient. Simple and easy to do....in theory, a little more difficult in practice.

Here are some hints--look at the patient's history, and the physician's orders.

Personalizing a care plan to the patient can be as easy as stating something like "titrating o2 to keep SpO2 >90%, as per physician order" or "Aerosolized albuterol treatments q4h and prn wheezing, dyspnea (as per physician order)" PT/OT orders, diet orders, activity orders, med orders, all these things can be used to personalize care plans.

If the standardized care plan mentions ambulating in halls TID but the patient isn't ambulatory, then you personalize it to that patient. Something like institute passive ROM TID to maintain strength et promote circulation. If a patient comes in and cannot adequatey reposition herself, personalizing the care plan would be to institute a nursing action of turning the patient q2h et prn to maintain skin integrety r/t pt's weakness, lack of activity.

Another personalization would be a patient with a history of CHF. Even if the doc didn't order strict I/O or daily wieghts, you would implement these based on the pt's history--again, another means of personalizing the care plan.

Does that help at all? Or were you already doing these things, and the instructor wants even more?

Apr 5, '07

I think I might know what your instructor is getting at. Once you figure out how care plan/nursing diagnosis books are set up and how the nursing process works, it is quite easy to just turn to appropriate pages and basically cut and paste the things that apply to your patient. What your instructor is wanting you to do is to customize it a bit. You should always integrate the medical plan of care with the nursing plan of care; the two should never clash. You also need to do a thorough assessment of the patient and their ability to perform ADLs.

If there is something specific about the patient that you have to amend in particular, then it should be included in the care plan. For instance, if the patient's medication has to be crushed and the patient will only take it if it is placed in chocolate pudding (I've had patients like this) it should become something addressed as a nursing intervention in a Feeding Self-care deficit. Sometimes patients can't tolerate being repositioned on one side or another. That is a personalized thing that needs to go in a care plan. It is usually things that you will only discover from your observations and working with the patient that are going to be revealed that will make care plans more personalized. Because I worked a lot of night shifts and did a lot of daily weights I can tell you that some patients had to be weighed on our chair scale because they didn't have good enough balance to stand on our regular scale. We also had a bed scale. Once we knew which scale worked best we put it in the care plan so others didn't have to waste time figuring this out and the patient put through the discomfort and safety risks of experimentation. Personalization can be as simple as knowing that paper tape is irritating to a patient's skin as opposed to plastic tape. Knowing those little things and including them in care plans is another way the instructor is able to tell if the care plan is personalized or not. If you are not getting close enough to patients to get that kind of personal information, your care plans will be pretty much sound like they are "canned".

Apr 5, '07

God help me, I am truly not trying to be a jerk....why wouldn't a care plan be specific to the patient you're writing it on? I thought that's what a care plan was. Again - not trying to be a rat...

Apr 6, '07

I've been doing those things, and I've been trying to make sure I set the goal with the client (Like I've been asked to do.) That being said, I talked to my instructor and she took one of my dx's Risk for infection r/t colon resection surgery. This client has been running high WBC's and my Noc is Infection control. The goal that I have for my client is Client will maintain or improve WBC counts through 4/6/07. Ok.... I understand this. she said she wants numbers for what we are trying to get the WBC's down to and what the numbers are right now. But now, she is asking me what the client wants her WBC's down to. ??? This client is 90 years old. I have a hard time getting her to understand how to rate her pain because of forgetfulness. She has difficulty deciding what clear liquids to choose for her diet. (Clear liquid diet) So, I'm supposed to be able to get my client to give me a number which means I would have to get into quite a bit of detail with this lady, and it will confuse her more. I don't think I should scrap this dx, but what do they want??

Apr 6, '07

Maybe offering your firstborn son? Or writing you careplan in your own blood?

Seriously, I would give the number that the lab in your hospital says are normal, and if your nursing instructor is so daft as to want you to ask the client what her own personal goal for a WBC, I would say that you should assume that the pt wants her WBC to be normal, and enter that into your goal.

I think your instructor sounds a bit off.

Apr 6, '07

Use the book as a guide, but simplify the material by restating it your own words. The instructor wants you to demonstrate that the info has passed through your brain with respect to your pt and is not just another *cut and paste* job, and that you are adding in your own critical thinking based on your patient's unique needs. I think the best way to do that is to include things the book doesn't say, i.e. cannot say, because of your patient's individual situation. Also leave out what doesn't really apply.

My clinical instructor hates the copy-cat stuff, because she can't get a read on whether the student really understands the process or is simply going through the motions mechanically just to have something to hand in. It sounds like that may be what's going on in your case. If so, you can make it easier on yourself by giving the instructor proof that you are critically thinking through the needs of your patient.

I've been doing those things, and I've been trying to make sure I set the goal with the client (Like I've been asked to do.) That being said, I talked to my instructor and she took one of my dx's Risk for infection r/t colon resection surgery. This client has been running high WBC's and my Noc is Infection control. The goal that I have for my client is Client will maintain or improve WBC counts through 4/6/07. Ok.... I understand this. she said she wants numbers for what we are trying to get the WBC's down to and what the numbers are right now. But now, she is asking me what the client wants her WBC's down to. ??? This client is 90 years old. I have a hard time getting her to understand how to rate her pain because of forgetfulness. She has difficulty deciding what clear liquids to choose for her diet. (Clear liquid diet) So, I'm supposed to be able to get my client to give me a number which means I would have to get into quite a bit of detail with this lady, and it will confuse her more. I don't think I should scrap this dx, but what do they want??

Are you sure your instructor wanted you to consult the client about where she wants her WBCs to come down to? --I would clarify that with the instructor, because that is probably a misunderstanding. Normal range (based on the agency's normals) would be an appropriate goal for a patient with an elevated WBC. It sounds to me like your instructor just wants you to be more specific, i.e. quote the client's lab finding, and for a goal quote the normal range of the agency for that lab.

Apr 7, '07

Nope not a misunderstanding. I survived it though. Thanks for all your help!!

Apr 7, '07

Very well said. My Instructor also asked for us to taylor the care plan to the patient and once you understand what they're asking, it comes fairly easy.